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Quality and Safety

IMPROVING CARE THROUGH NURSE EMPOWERMENT

Hospitals strive to provide care that is safe, efficient, effective, patient centered, timely, and equitable, said Maureen Bisognano, executive vice president and chief operating officer at the Institute for Healthcare Improvement (IHI). But variations in safety and quality in hospitals across the United States and worldwide are disquieting, as discussed below:

  • Safety: Patients in U.S. hospitals experience many preventable adverse drug events. Approximately 90,000 patients die from infections acquired at U.S. hospitals each year, according to the Centers for Disease Control and Prevention (Wenzel and Edmond, 2001). A patient entering a U.S. hospital is about to experience the eighth greatest health hazard in the country, Bisognano said.

  • Effectiveness: Variations in outcomes from one hospital to the next or even from one unit to another are “too wide for us to accept.” There is a failure to identify best practices within a single hospital and share those practices across the units and with multiple hospitals.

  • Efficiency: Even as hospital costs continue to rise at rates higher than inflation, evidence shows that hospitals with particularly high costs do not necessarily provide higher quality care. Waste is present in most hospitals. It causes delays in care and has both human and financial costs.



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3 Quality and Safety IMPROVING CARE THROUGH NURSE EMPOWERMENT Hospitals strive to provide care that is safe, efficient, effective, patient centered, timely, and equitable, said Maureen Bisognano, execu- tive vice president and chief operating officer at the Institute for Health- care Improvement (IHI). But variations in safety and quality in hospitals across the United States and worldwide are disquieting, as discussed below: • Safety: Patients in U.S. hospitals experience many preventable adverse drug events. Approximately 90,000 patients die from infections acquired at U.S. hospitals each year, according to the Centers for Disease Control and Prevention (Wenzel and Edmond, 2001). A patient entering a U.S. hospital is about to experience the eighth greatest health hazard in the country, Bisognano said. • Effectiveness: Variations in outcomes from one hospital to the next or even from one unit to another are “too wide for us to ac- cept.” There is a failure to identify best practices within a single hospital and share those practices across the units and with mul- tiple hospitals. • Efficiency: Even as hospital costs continue to rise at rates higher than inflation, evidence shows that hospitals with particularly high costs do not necessarily provide higher quality care. Waste is present in most hospitals. It causes delays in care and has both human and financial costs. 15

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16 FORUM ON THE FUTURE OF NURSING: ACUTE CARE • Patient centeredness: Many systems and processes are still de- signed to meet the needs of providers rather than patients. True patient- and family-centered care will focus on the whole patient, putting the patient, family, and care team together as a system. • Timeliness: Delays impose costs not only on hospitals, but on patients in terms of questions unanswered, delayed diagnoses, suffering incurred while waiting for treatments, and lack of co- ordination. Yet some hospitals have demonstrated that delays in surgeries, for example, can be virtually eliminated. “Our mantra should be: the right care, in the right place, at the right time, in every place in the country,” Bisognano said. • Inequity: Continued variations in care delivered and outcomes among socioeconomic and ethnic groups remain unacceptable. Improvements in the quality of hospital care often occur as a result of national campaigns or programs. By identifying a small number of goals, Bisognano said, such initiatives can work to close gaps among settings. For example, the Commonwealth Fund Commission on a High- Performance Health System has supported the development of a state scorecard on health system performance that has made it possible to translate best practices and knowledge across the system. On a set of hospital clinical quality indicators, the rates in the five lowest performing states approached the previous levels of the highest performing states (McCarthy et al., 2009). “We are starting to see a national awareness of quality and safety and the beginnings of a system to share” best practices and knowledge. Nurses play a unique role in ensuring quality and safety in hospitals, Bisognano said. “We are the pivot point, we are the people who spend the time, we are the people who see patients across transitions in care.” Yet nursing faces many challenges. Care is becoming more complex even as hospital stays become shorter. The nursing population is growing older. The average age of nurses is 44, with many older nurses returning to the workforce in the current economy. Despite the increasing average age of nurses, hospitals are imposing uniform standards and workloads on all nurses. Turnover of nurses is high, shortages of nurses are loom- ing, and nursing staff levels are inadequate in many locations. Finally, nurses still experience an unacceptably high number of work-system failures (an average of 8.4 times per 8-hour shift) and interruptions (an average of 8.1 times per 8-hour shift) (Tucker and Spear, 2006). “Poor

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17 QUALITY AND SAFETY system design and the failure to coordinate are going to produce bad re- sults even in the most experienced and savvy nursing staff.” As part of her work at the IHI, Bisognano observes nursing units in hospitals around the world. She described a particular set of innovations at a small community hospital in Cedar Rapids, Iowa, as an example of what can be achieved. When she walked into the hospital, she found a design totally focused on nurses and patients. Everything they need is built into the unit. For example, the dieticians in the hospital are directly linked to the units so they can bring a mobile cart to sit down and coun- sel patients on their dietary choices. Doctors and nurses make rounds that include not only the patients, but also their families. All family members are welcome to visit patients at any time, and when they walk into a pa- tient’s room, the atmosphere is calm and welcoming. Bisognano described how all the rooms are same-sided—organized in such a way that equipment and supplies are always located in the same place—“a nurse can literally put out his or her hand and find the supplies and equipment needed.” The flows and zones for caregivers, patients, and families are clear and built into the designs, eliminating the need for hunting and gathering. Nurses can focus on the kind of work they should be doing: assessment and patient interactions. Caregivers are organized into multidisciplinary teams, with physi- cians, nurses, dieticians, social workers, the palliative team, pastoral workers, and therapists readily available on the unit. As a result, nurses do not have to do time-consuming coordination work and can focus on care. Even the quality and outcome research staff are located on the unit, not in an administrative building. “System connections are everywhere,” Bisognano said. “Patients are getting better care . . . in the hospital, pre- hospital, and also in the community for hospice.” Technology is used to support the frontline staff, with physicians and nurses collaborating on the design and use of technology. For example, technology links the staff remotely for direct patient visual and vital-sign monitoring. Because of these technology-mediated connections, “the sense of trust in the nursing staff is palpable.” The nursing staff returns and earns that trust. For example, when a flood in Cedar Rapids forced 300 patients to be evacuated from the hos- pital within 3 hours, many off-duty nurses arrived to move sandbags and transport those patients to other hospitals as far as 200 miles away. Bisognano offered six priorities for the committee to consider. “If each of these changes happened in hospitals across the United States,

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18 FORUM ON THE FUTURE OF NURSING: ACUTE CARE quality and safety would be increased and costs would be reduced,” she explained. 1. Redesign care to optimize nurses’ professional expertise and knowledge. The goal should be for nurses to spend 60 percent of their time in direct patient care (RWJF and IHI, 2007). Accord- ing to Bisognano, when this goal is met, not only will nurses be happier in their work, but also they will be providing care that is more effective and less costly. “Increasing value not only pro- duces better efficiency, but also produces better outcomes.” 2. Focus on transformational leadership at all levels. Nurses should be engaged and empowered to act as leaders at every level, Bisognano said. For example, nurses should be on hospital boards to think strategically about change—“How do we get nursing to help patients across the vast continuum of care?” Nurse leaders should work side by side with physicians to design the quality priorities for the organization. “All frontline nurses deserve training in quality improvement so they can redesign the processes of care at a patient’s bedside.” 3. Work together to ensure safe and reliable care in acute settings. Today, few hospitals have effectively implemented systems to identify and reduce errors. Yet the safety literature suggests that more than 70 percent of errors happen not because of incompe- tence, but because of system failures (Leape et al., 1993). Each failure should be used as a lesson to make system improvements. Examples of learning systems include medication system redes- ign, end-of-life best practices, and the use of rapid-response teams to rescue patients when their condition deteriorates. 4. Build systems and cultures that encourage, support, and spread vitality and teamwork in all areas of nursing. Bisognano said she has seen nurses walk off the unit at the end of the day exhausted from working in poorly designed workflow processes, and with- out the skills they need to make the changes on the front line. She also has seen nurses who feel fulfilled and vital, and who are respected at the end of a long and hard shift because work proc- esses have been designed to support their professional skills. For example, health professionals who are confident in their ability to communicate with coworkers about concerns produce better patient outcomes and are more satisfied and engaged in their work (Maxfield et al., 2005).

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19 QUALITY AND SAFETY 5. Put structures and processes into place that ensure patient- centered care. Such care honors the whole person and family, re- spects individual values and choices, and ensures continuity of care as patients transfer from one setting to another. In most hos- pitals, systems and processes are still designed to meet the needs of the providers, not the patients. In Bisognano’s experience, care teams that work with patients and families to establish daily goals and patient preferences not only provide better care, but re- sult in fewer readmissions, failures, and complications. Nurses are the logical people to create innovative new models to spread the best clinical care across the continuum. 6. Create a national learning system to make all models and proto- types accessible to nurses at all levels everywhere in the country. Bisognano repeated Marilyn Chow’s injunction: “We are excel- lent at everything, but excellence is just not everywhere.” The tools exist to close gaps and fulfill the promise to patients. VALUE, RELIABILITY, AND COLLABORATION IN NURSING Tamra Minnier, chief quality officer at the University of Pittsburgh Medical Center (UPMC), emphasized three points that would make a great impact in the future of nursing: 1. The courage to stop doing work that is not value added. 2. The ability to build reliable nursing care delivery systems. 3. The redesign of care teams led by nurses. As a simple example of work that is not value added, Minnier cited fall risk assessments. At UPMC, the fall screening admission assessment had grown to 24 sections on paper and 30 sections as an electronic record. A major redesign effort reduced the size of the form to just three questions. “The third question really threw people—in your judgment, as a nurse, do you think this patient is going to fall? God forbid that we let you think!” The redesign led to a 90 percent reduction in nurses’ time to fill out the electronic record and an 87 percent reduction in the time to fill out the paper record. Although the design seems straightforward, said Minnier, it actually required considerable courage. People had a tendency to ask, “What

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20 FORUM ON THE FUTURE OF NURSING: ACUTE CARE about this or what about that?” But building systems to the exception rather than the rule makes them cumbersome and difficult to successfully manage. Reliability is a design feature well known to engineers, but rarely emphasized in nursing. The example Minnier used to describe the impor- tance of reliability is the failure to prevent skin breakdowns. Nearly 500 patients at UPMC hospitals develop hospital-acquired pressure ulcers over the course of a year. Nurses “feel absolute personal failure when that happens.” A major cause for the problem is that nurses too often have to combine work that needs to be done reliably with work that arises unpredictably. “We expect people to do steady, consistent work while they are being interrupted hundreds and hundreds of times a day.” Reliability needs to be a bedrock feature of nursing systems, Minnier said. Reliable work is the essential, routine work done to maintain basic patient care standards. It includes tasks such as admission assessments, medication distribution, assistance with activities of daily living, turning, risk assessment, wandering assessment, comfort rounds, and environ- mental checks. Unreliable, or unpredictable, work occurs randomly over the course of 24 hours and includes activities such as preparing or trans- ferring a patient for testing or procedures, answering call bells, family communication, placing a patient in isolation, and emergencies. Splitting of routine and unexpected tasks will allow reliability to be built back into the systems and will allow teams to be built around these different sets of responsibilities. Finally, nurses need to lead care teams. In the past, physicians have often been seen as the “captain of the ship” in hospitals. “We need our physician colleagues for many components of care delivery, but we know, in the end, who actually delivers that care and coordinates that care: It is the nurse,” Minnier said. Nursing staff need the right tools and nurse-driven protocols to redesign nursing and transform care at the bed- side. For example, teams might be designed that include a care nurse leader; a reliable, uninterrupted rounder doing predictable tasks; a medi- cation nurse; and so on. “I don’t have all the answers. None of us has the answers individually, but collectively we do.” The important point is that a team is needed to care for a patient—and the patient should be seen as part of that team. Patients deserve to have their needs met every time, Minnier said, and staff deserve to do an excellent job every time. The system needs to support both these needs by making work easier. Redesign of the system needs to build reliability into processes, promote continuous workflow

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21 QUALITY AND SAFETY by reducing interruptions, assign tasks to the right individuals, remove waste and redundancy, and test in order to learn. “It begins with trust— trusting what we know is right.” Nursing has arrived at the right moment to make changes, Minnier said. “We have been in this current state for way too long,” she said. “It has a degree of inertia. It sometimes feels insurmountable. . . . But we must muster the courage to make it different.” REACTIONS FROM RESPONDER PANEL In response to the presentations from Bisognano and Minnier, Dr. Julia Hallisy, a dentist representing the Empowered Patient Coalition, observed that patients and their families are “the most underused re- sources in the acute care system today.” Patients recognize that nurses need to be as efficient and as productive as possible, and many patients are willing and able to be engaged as care partners. Patients know they will be safer when nurses spend more time at the bedside. They also know that, when a new procedure or technology is implemented at a hospital, nurses are usually the ones who will be doing the implementa- tion and will be the first to know what works and what does not work. Patients and their families realize that the person at the bedside is the one who first recognizes the signs of deterioration, but this requires that nurses spend time at the bedside rather than being constantly distracted. Finally, patients and their families value communication with physicians and nurses, requiring that patients and their families be encouraged to communicate, educated in the best ways to communicate, and included on formal bodies such as advisory committees so their voices can be heard. Dr. Joseph Guglielmo, professor and chair of the Department of Clinical Pharmacy at the University of California–San Francisco School of Pharmacy, emphasized that communication has to occur among the staff in a hospital, including between pharmaceutical services and nurs- ing. Sometimes this relationship can be adversarial, but his institution has fostered a collaboration that is based on being proactive rather than reac- tive. “We cannot communicate too much, and I include my hospitalist colleagues and other physicians in those problem-solving processes as well,” Guglielmo said. Dr. Kurt Swartout, chief of Hospital Medicine at Kaiser Permanente Roseville Medical Center, pointed out that quality measures are often

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22 FORUM ON THE FUTURE OF NURSING: ACUTE CARE based on single outcomes, such as falls or infections. However, empha- sizing those measures risks missing the overall picture. Many patients present with so many different problems that outcome-based measures would be a better way to drive quality improvements, he said. Dr. Bernice Coleman, acute care nurse practitioner at Cedars-Sinai Medical Center, said nurses have the answers to many problems if they are given the opportunity to develop those answers. “To have nurses bring value to some of the solutions, we, as leaders, have to allow that to happen.” At the same time, leaders must act from a patient-centered per- spective. Once patients are discharged back into the community, care providers need to stay connected with the patient. “We [need to] design systems such that the continuing care that happens in the hospital, with nurses and teams, continues after discharge.” Finally, Nancy Chiang, former secretary/treasurer of the California Student Nurses Association, noted that student nurses often believe they do not get to spend enough time with nurses in a clinical setting learning their profession. Improvements in communications between patients and nurses also would be beneficial for nurses and nursing students. Simi- larly, students could benefit by spending more time with other members of care teams. COMMITTEE QUESTION-AND-ANSWER SESSION In response to a question about how patient-centered care should be defined, Bisognano said patients should be asked to rate their agreement with the following statement: They give me all the care I want and need, exactly when and where I want and need it. She agreed that many exist- ing metrics looked at clinical processes rather than care from the per- spective of the patient. She also noted that care is much more patient centered in other countries than in the United States. She described a friend’s account of her father’s experience after breaking a hip in Eng- land. “The day before he went home, a nurse-led squad arrived at the house . . . and went through the entire house with her mother. They in- stalled a grab bar in the shower, a [seat] on the toilet so he could get up and down. They handed the mother the pain medication and went over diet. They tacked down the rugs and talked about how to take care of his wound. That is patient-centered care, and the patient won’t be readmitted because the nurses are carrying that patient care from one setting to an- other. We need to figure out how to measure that.”

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23 QUALITY AND SAFETY Bisognano also pointed out that the involvement of students with nurses who have a variety of experiences and expertise is essential. She described a chief executive officer who posted a sign at his hospital say- ing, “Every patient deserves an experienced nurse, and every nurse de- serves an experienced nurse.” A metric such as years of experience among the nurses working per shift could help ensure that patients and other nurses benefit from experienced nurses. In response to a question about how hospitals can use patients and their families as a resource, Minnier observed that patients and families can make a big difference in health care. For example, they can be given a specific assignment, such as keeping the head of a bed elevated to avoid ventilator-associated pneumonias. Her hospital also has imple- mented a program in which patients and families can call for rapid- response teams in case deterioration in a patient’s condition is noted, providing “a set of eyes and ears that we don’t have.” Minnier also provided several examples of nurse-specific pro- tocols response to a question from the committee. She highlighted protocols such as deciding when to culture a patient for Clostridium difficile or knowing when a patient is ready to be discharged. “These lev- els of empowerment are some of the strategies for the future that we need to consider.” A questioner asked whether the current national discussion about health care reform might affect nursing. Bisognano replied that the na- tional discussion has so far centered on health payment reform rather than health care reform. The IHI recently brought together representa- tives of 10 institutions that had low costs and high-quality outcomes at a meeting entitled “How Do They Do That?” These models of excellence need to become visible, she said, so that as health care reform progresses, any hospital can adapt proven practices to local circumstances. Chow observed that a problem with health care is that “we all seem to learn the same thing over and over again.” An infrastructure needs to be established that will allow the system to reach a higher level. How can high standards and best practices not only be identified, but disseminated and implemented? A committee member asked what has kept the health care system from implementing efficient processes. Is it a lack of financial incentives, money, nurse empowerment, or some other factor? Chow replied that hospitals were not designed through a holistic process. Instead, depart- ments created their own processes over many years, and these processes were not necessarily designed to work together or accommodate the

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24 FORUM ON THE FUTURE OF NURSING: ACUTE CARE needs of nurses and patients. Also, there is an inertia in hospitals that works against change and a “not invented here” syndrome that keeps promising innovations from other places from being accepted. Until de- partments come together to redesign care around the needs of patients, hospitals will continue to develop in a haphazard way. Minnier noted that many leaders in hospitals do not fully understand the issues that face nursing and fail to keep the care of patients front and center, “whether [because of] unaligned incentives, lack of knowledge, or lack of understanding.” National programs such as Transforming Care at the Bedside can elevate issues to a level beyond the institution and lead to meaningful change. Also, one step the IHI has taken is a program to build the skills of physicians, nurses, students, administrators, and oth- ers to fix broken processes on the front line.